Assisted Conception

There are a number of different assisted conception treatments available and all of them aim to increase the chance of pregnancy by enhancing what happens in nature.

The main techniques for assisting conception are:

Assisted insemination (also known as intrauterine insemination, or IUI)

Ovulation induction

In vitro fertilisation (IVF) and its variations.

Assisted Insemination

Assisted insemination, or intrauterine insemination (IUI), is a technique in which sperm are placed into a woman’s cervix or uterus, using a soft, thin plastic tube around the time that ovulation is expected.

The cycle is monitored closely with blood tests and ultrasounds to time insemination as precisely as possible. Depending on the woman’s ovulation pattern, insemination may or may not be preceded by ovarian stimulation.

This technique is used only in a few circumstances, for example when:

there is a physical problem with sexual intercourse

scarring of the cervix prevents sperm penetration

donor sperm is required

If there is a low sperm count, endometriosis or blocked fallopian tubes, assisted insemination is not as effective as IVF. Assisted insemination is not recommended when the cause of infertility is unknown.

Ovulation Induction

For women who have normal tubes but rarely or never ovulate and whose partners have a normal sperm count, Ovulation Induction (OI) using hormones to provide controlled ovarian stimulation may be recommended, using tablets or injections.

The most common cause of anovulation is polycystic ovaries. For those women who regularly ovulate, stimulation can be utilised to increase the chances of pregnancy as it increases the number of follicles that develop fully, therefore the number of eggs ovulated during a cycle. This process does however carry a risk of multiple pregnancy and there is a direct correlation between your chance of pregnancy and risk of a high order multiple pregnancy.

In vitro fertilisation (IVF)

IVF is the process in which a woman’s eggs are fertilised outside the womb.

Every month in a natural cycle, up to 30 small follicles containing immature eggs, known as ‘recuits’, will start to develop. With the brief rise in follicle stimulating hormone (FSH) that a woman produces naturally, only 1 of those follicles will grow up, dominate and ovulate.

With IVF, the goal is to keep the level of FSH constant to encourage more of the recruits to develop mature eggs. These eggs are then collected in a minor transvaginal surgical procedure, under sedation and local anaesthetic, using ultrasound guidance.

Some women will choose to have a general anaesthetic for the procedure. The eggs are then fertilised in the laboratory and cultured for several days before one embryo (rarely two) is transferred to the woman’s uterus. Additional good quality embryos can be frozen and stored for later use.

In conventional IVF, between 50,000 and 100,000 sperm are placed in a container with the woman’s eggs. Over the next few hours the sperm will gradually work through the outer cells and hopefully one sperm will successfully fertilise the egg.

A day after the sperm has been introduced to the eggs, they will be checked to see if the eggs have fertilised successfully. This is recognised by the presence of pronuclei and, in normal fertilisation, there should be two pronuclei – one from the sperm and one from the egg.

A good result is if 80% of the eggs collected have two pronuclei on Day 1. Several days later one embryo will be transferred to the woman’s uterus and additional good quality embryos can then be frozen and stored for later use.

PGD Analysis

Human beings are very inefficient reproducers. The majority of embryos that we make, whether in nature or in the IVF lab, don’t have the correct number of chromosomes.

If an embryo fails to implant, or if it miscarries, that is almost always because it was chromosomally abnormal. We can’t tell if an embryo is normal or not just by looking at it, and statistically around half of blastocysts will not be normal. Even the most beautiful blastocyst may be hopelessly chromosomally abnormal.

One of the greatest breakthroughs in IVF technology in recent years has been the advent of preimplantation genetic diagnosis (PGD). Scientists can take cells from the part of the embryo that becomes the placenta and count its chromosomes or look for specific gene defects.

Testing embryos doesn’t change them, and having a normal embryo doesn’t guarantee that it will become a baby. But if a couple have a number of blastocysts we can determine which ones will never become healthy babies and therefore limit the number of times an embryo transfer will fail.

Our goal is to limit the number of times a woman has to go through ovarian stimulation and egg collection, which is the most physically, emotionally and financially difficult part of the IVF process. If you’re considering IVF, PGD could be an important part of the equation towards you achieving your goal faster.

Preimplantation genetic diagnosis (PGD)

PGD involves analysing the cells removed from an embryo on day five or six of development.

From this tiny sample, we can determine whether an embryo has a wide range of genetic problems that might occur in a particular family.

Most commonly, PGD is used when a couple are aware of the possibility that their offspring will inherit a specific genetic disease for which one or both of the intended parents is known to be a carrier. Even though they are fertile, they choose IVF to produce embryos that can be tested before the couple actually conceive a pregnancy. Only embryos that do not show the disease are then transferred.

PGD may be recommended for people who:

are affected by or carry the gene for a particular disease;

have had recurrent miscarriages; or

need to choose the sex of their baby for medical reasons.

Intracytoplasmic Sperm Injection (ICSI)

If the chance of fertilisation with conventional IVF is poor, then a procedure called Intracytoplasmic sperm injection (ICSI) can be used.

This involves the injection of a single sperm into each egg.

Blastocyst culture

Once fertilisation has occurred, the cells will naturally divide and increase in number over the following days.

While many embryos will survive for a few days to reach the 4-8 cell stage, only the strongest have the ability to develop into a blastocyst and then a baby.

At this stage the embryo has over 100 cells, comprised of a layer of outer cells (the trophectoderm) surrounding a fluid-filled space (the blastocele) in which an inner group of cells can be seen. The trophectoderm will go on to form the placenta, membranes and umbilical cord, while the inner cell mass will become the baby.

It’s not possible to tell a ‘good’ embryo versus a ‘bad’ embryo just on appearances. One way of identifying the better embryos is to let them grow to the blastocyst stage as from here it can be seen which will have the most developmental potential.

Fertility Preservation

There are a number of reasons that couples or individuals may want to consider preserving their fertility.

One of the more common is in advance of a potentially fertility-reducing situation, such as chemotherapy or major ovarian surgery. We now have decades of experience in storing embryos and the success rate with frozen is the same, if not better, than with fresh embryos. For couples seeking to preserve their fertility, this would be the recommended option.

The same vitrification technology that is used in embryo cryopreservation can also be applied to freezing mature oocytes. A very fragile structure, the human egg contains a large amount of water that can form damaging ice crystals during the freezing.

Reports exist of hundreds pregnancies from frozen oocytes but what is unknown is how many eggs were required to achieve each pregnancy, which makes it impossible to know the success rates. If you are concerned about your future fertility, it is best to have a consultation to discuss your individual situation.

Donor Eggs and Sperm

Donated eggs or sperm may present the only opportunity for some people to have a baby who otherwise wouldn’t be able to do so.

In many cases, the medical procedures required are relatively straightforward though careful thought and consideration needs to be given to this option before making the decision to go ahead with it.

Egg donation

The decision to have a baby using eggs donated by another woman can come about for a number of reasons, such as early menopause, illness or failed IVF. Whatever the reason, the choice to use donor eggs or become a donor is a complex one that needs very careful consideration.

In Australia, donors cannot be paid and egg donation is done altruistically. Donors may be members of the community but generally the recipient will know them – such as a friend, sister or cousin. Some people will choose to travel overseas for “commercial” egg donation.

Sperm donation

In some cases, sperm donation may be your best option for having a baby – if the male partner has no healthy sperm of his own, you’re a single woman or if you are in a same-sex relationship.

Surrogacy

Surrogacy is when one woman carries a baby, which is not genetically her own, and delivers it for another person or couple.

Surrogacy is an option for women who are unable to carry their own baby throughout the pregnancy or for same sex male couples. As with egg donation, surrogacy in Australia is done altruistically. In New South Wales, it is currently illegal to travel overseas for commercial surrogacy.